RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02530
BRANCH OF SERVICE:  nAVY 	SEPARATION DATE:  20040105

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Electrical Mechanical Equipment Repairman, medically separated for “bilateral proximal tibial stress fracture” with a disability rating of 10%.

CI CONTENTION:  “Review all conditions.”  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the panel’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determinations is based on review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The panel has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20031126	VARD - 20040223	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Proximal Tibial Stress Fracture	5022-5003	10%	Left Proximal Tibial Stress Fracture	5262	0%	STR	
			Right Proximal Tibial Stress Fracture	5262	0%		
Stress Fractures Changes of the Right Tibial Plafond and Right Medial Tibial Plateau	Cat III	Multiple Right Lower Extremity Stress Changes (…Tibial Plafond, Tibial Plateau…Medial Femoral Condyle…)	5255-5262	NSC		
Medial Right Femoral Condyle						
Left Calcaneal Stress Fracture	Cat III	Left Calcaneal Stress Fracture	5284	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Tibial Stress Fracture Condition.  The PEB combined the right and left tibia conditions as a single unfitting condition coded 5022-5003 (periostitis-arthritis, degenerative) and rated 10%.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The panel also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right and left tibia conditions are presented together, with attendant recommendations regarding separate unfitness and rating, if applicable, in the rating discussion.

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the bilateral lower extremity (LE) conditions began in August 2003.  Radiographic studies on 11 September 2003 showed healing stress fractures involving both proximal tibias and on 24 September 2003 showed minimal reactive change about the left anterior tibial tubercle which could reflect some stress related change.  

The 27 October 2003 MEB NARSUM examination, 2 months prior to separation the CI complained of 7-8/10 pain in the right thigh and leg after prolonged weight bearing.  The bilateral LE examination revealed focal tenderness to deep palpation of the left calcaneus, right proximal tibia, and right distal femur with no skin changes or swelling.  “Range of motion [was] full and equal bilaterally.”  Strength and sensation were normal.  

The 19 November 2003 orthopedic surgery follow-up documented “no pain except occasional knee pain.”  The physical examination revealed no focal tenderness to palpation, skin changes, or edema (excess tissue fluid swelling).  The assessment listed bilateral LE healing stress fractures. 

As previously elaborated, the panel first considered whether each tibia condition remained separately unfitting, having been de-coupled from the combined PEB adjudication.  The panel concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case.  The panel then directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating for the bilateral tibias under the 5022-5003 codes citing bilateral proximal tibial stress fractures.  The VA assigned a 0% rating for the right tibia and a 0% rating for the left tibia under the 5262 code (tibia and fibula, impairment of) based on the STR and documenting that the CI failed to report for a scheduled VA examination.  The VA cited proximal tibial stress fractures, full LE ROM, intact LE motor strength and sensation, and absence of existence of a tibia malunion with slight knee or ankle disability.  The panel noted that with light duty and leg rest, there was progressive improvement of symptoms and stress fractures/changes by serial examinations and imaging studies.  The ROM values did not support a minimum rating under the limitation of knee flexion (5260), knee extension (5261), and ankle limited motion (5271) codes.  There was no dislocated meniscus (5258), symptomatic removed meniscus (5259), knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  There was no ankle ankylosis (5270), subastragalar or tarsal joint ankylosis (5272), os calcis or astragalus malunion (5273), or excision of the astragalus (5274) for consideration under the respective codes.  The panel agreed a 10% rating was not supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  The panel also agreed that the combined rating of 0%, coded 5022-5003, was a good analogy to both the pathology and disability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change to the 10% PEB adjudication for the bilateral tibia conditions.  

Contended PEB Category III Conditions:  Stress Fractures Changes of the Right Tibial Plafond, Right Medial Tibial Plateau, Medial Right Femoral Condyle, and Left Calcaneal Stress Fracture.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  While “multiple stress fractures” were implicated in the non-medical assessment (NMA), Category III conditions by definition are not separately unfitting, and do not contribute to the unfitting condition.  Although the Category III conditions were judged to fail retention standards, there was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral proximal tibial stress fracture conditions and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended stress fracture changes of the right tibial plafond, right medial tibial plateau, medial right femoral condyle, and left calcaneal stress fracture conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150801, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC

		
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	     				  Acting